Home News Briefs Final rules on two-midnight, advance planning

Final rules on two-midnight, advance planning

Plus, does defensive medicine really work?

December 2015

Published in the December 2015 issue of Today’s Hospitalist

Final two-midnight,
 advance planning rules

IT’S OFFICIAL: Proposed changes that the Centers for Medicare and Medicaid Services (CMS) announced in July have been issued as final rules. Those include a relaxation of the controversial two-midnight rule, as well as payments for clinicians for advance care planning discussions with patients.

According to Oct. 30 coverage in the New York Times, patients and families can have end-of-life discussions with physicians even if they’re not ill. Under the new rule for advance care planning, the CMS will pay $80 for the first 30 minutes of such sessions in the hospital ($86 in a physician’s office) and up to $75 for 30 additional minutes. The codes associated with the new rule go live Jan. 1.

As for the two-midnight rule, the CMS is giving physicians more flexibility to use their medical judgment and admit patients as inpatients who aren’t expected to remain in the hospital more than two midnights. Moreover, the CMS has turned initial review of two-midnight claims over to quality improvement organizations, rather than to recovery audit contractors.

Study backs intensive 
blood pressure control

NEW DATA endorse intensive blood pressure control among patients at high cardiovascular risk, according to study results published online last month by the New England Journal of Medicine.

In the SPRINT trial, more than 9,300 patients were randomized to either intensive treatment (a systolic blood-pressure target of less than 120 mm Hg) or standard treatment (a target of less than 140 mm Hg). Patients in the intensive-care arm, who had an average achieved systolic blood pressure of 121.5 mm Hg, had a lower rate (1.65% vs. 2.19% per year) of the primary composite outcome, which included MI, other ACS, stroke, heart failure or death from cardiovascular causes.

The intensive-treatment arm also had lower all-cause mortality. However, those patients also had higher rates of hypotension, syncope and electrolyte abnormalities, as well as of acute kidney injury or failure. The trial was stopped early after a median follow-up of more than three years.

A meta-analysis published online last month by The Lancet also found “clear evidence of the benefits of more intensive blood pressure lowering.”

Does defensive medicine 
work after all?

A NEW STUDY SUGGESTS that defensive medicine may indeed protect physicians from being sued.

Writing in BMJ, researchers tracked both spending and malpractice claims for Florida physicians over nine years (2000-09). They found that in six out of seven specialties, the doctors who spent the most in terms of health care resources were sued the least.

Among internists, for example, only 0.3% of those who chalked up the highest hospital costs were sued, compared to 1.5% of internists with the lowest hospital charges. The authors looked at data on more than 24,600 physicians and more than 18 million hospital admissions. Malpractice claims were made against 2.8% per physician year.

As the Washington Post reported in its coverage of the study, the findings might hurt physician buy-in for curbing excess health care spending, a key goal of health care reform.

AHA updates its
 CPR guidelines

FOR THE FIRST TIME IN FIVE YEARS, the American Heart Association has updated its CPR guidelines, setting upper limits on both the rate and depth of chest compressions and removing vasopressin from the ACLS algorithm.

According to the guidelines, which were published in the Nov. 3 issue of Circulation, the compression rate should fall between 100 and 120 per minute and the compression depth, which should be at least two inches for adults, should not exceed 2.4 inches.

Also new: The revised guidelines recommend the use of naloxone to resuscitate known or suspected opiate abusers. The guidelines also drop the use of vasopressin.

In addition, the guidelines make it clear that pre- and post-shock pauses should be as brief as possible, “because shorter pauses can be associated with greater shock success, ROSC [return of spontaneous circulation], and, in some studies, higher survival to hospital discharge.”

The AHA also announced that going forward, guidelines “which have recently been revised every five years “will now be continuously updated online instead.

PCI: No long-term benefit 
in stable heart disease

PUBLISHED IN 2007, the COURAGE trial randomized patients with stable ischemic heart disease to either medical therapy or medical therapy plus PCI. At that time, the authors found that PCI didn’t lower patients’ risk of death or cardiovascular events.

Now, the same research team has completed up to 15 years of follow-up on those patients, and it has reached the same conclusion. (The authors noted that the median duration of follow-up for patients in this extended analysis was 11.9 years.) Researchers were able to track survival information for 53% of their original cohort and found that PCI conferred no long-term survival benefit. Results were published in the Nov. 12 issue of the New England Journal of Medicine.

One of the study authors, who was quoted in HealthDay, reported that of the one million angioplasties done in the U.S. every year, 500,000 of them are performed on patients with stable heart disease.

Frequent pharmacist interventions 
curb readmissions

A NEW STUDY FINDS that having pharmacists intervene often with complex patients helps curb 30-day readmission rates and post-discharge ED visits.

In the single-site study, researchers randomized patients who were taking either high-risk medications or who had more than three prescriptions upon discharge. For patients in the study arm, pharmacists performed a face-to-face medication reconciliation, delivered a patient-specific prescription plan, gave discharge counseling and phoned patients three times post-discharge. Calls were placed on days 3, 14 and 30.

Among controls, 39% visited the ED or were readmitted within 30 days vs. 25% of those in the study arm. The study was unique, the authors wrote, in the number of post-discharge phone calls that pharmacists made and in pharmacists’ “integrated participation” in patient care.
However, the authors also pointed out, “no mechanism currently exists to directly reimburse for such efforts.” Results were published online in October by the Journal of Hospital Medicine.

What works in transitional care
 for HF patients?

A NEW META-ANALYSIS that looks at randomized data on different transitional care interventions for heart failure patients found that intervention intensity and duration have a big impact.

Writing in the November/December issue of Annals of Family Medicine, Canadian researchers assessed the impact of transitional-care interventions on readmission rates and ED visits after discharge among heart failure patients. They found that transitional care interventions did cut readmission and ED-visit rates by 8% and 29%, respectively.

However, the efficacy of interventions varied by intensity and duration. High-intensity interventions “such as combining home visits with telephone follow-up or clinic visits, or both “reduced patients’ readmission risk regardless of duration.

Moderate-intensity interventions, which included home visits only or a combination of telephone and clinic follow-up, did reduce rates of readmissions and ED visits, but only if they were implemented for at least six months. Low-intensity strategies with only telephone or clinic follow-up were not effective.

“High-intensity interventions seem to be the best option,” the authors wrote. “Moderate-intensity interventions implemented for six months or longer may be another option.”

Medication errors complicate 
one in 20 surgeries

ONE OUT OF EVERY 20 SURGERIES is complicated by a medication error or an adverse drug event, a rate “markedly higher” than reported in previous retrospective surveys. That’s according to a new study published in the October issue of Anesthesiology.

Anesthesia-trained staff spent eight months observing randomly selected operations at a 1,000-bed tertiary academic center. They found medication errors or adverse drug events in 5.4% of those operations, 79% of which were preventable. Among errors observed, 65% were serious, 33% were significant and 2% were life-threatening.

The authors noted that “specific solutions exist that have the potential to decrease the incidence” of perioperative medication errors. Examples of solutions included several that were technology-based, such as including point-of-care bar-code-assisted anesthesia documentation systems. The authors also recommended process-based interventions to reduce opportunities for workarounds and promote “rigorous vendor selection with strong training.”

Addressing medical interns’ suicidality

NEW RESEARCH INDICATES that a Web-based program of cognitive behavioral therapy (CBT) might reduce suicidal ideation during medical interns’ internship year.

Researchers randomized nearly 200 interns from multiple specialties at two academic centers to either a group that completed free online CBT modules or one that received weekly e-mails with information about depression and suicide. During the course of their internship year, those assigned to the CBT group were less likely to endorse suicidal ideation (12% vs. 21%).

The results were posted online in November by JAMA Psychiatry. The authors recommended incorporating such prevention techniques in medical training programs throughout the country, although they noted that few preventive efforts are currently being made. According to the study, suicidal ideation increases four-fold during the first three months of doctors’ internship year.

“In the United States, approximately one physician dies by suicide
every day,” they wrote. “Training physicians are at particularly high risk.”

Do you treat VIP patients 
any differently?

AND IF YOU DO, is that a good or bad thing? In a New York Times op-ed piece published in October, a Boston resident looked at how “red blanket” patients (celebrities, CEOs or wealthy friends of hospital trustees) are treated differently in hospitals and how his colleagues feel about that preferential treatment.

Some physicians, the resident wrote, have no problem with some patients paying more for “pavilion” amenities, including gourmet food and plushy rooms or suites. Such VIPs may want to make a big donation to the hospital after a successful stay. According to the author, some doctors in cancer centers are supposed to solicit just such donations.

But other physicians worry that VIP patients actually receive worse care and are subjected to unnecessary testing. In his own practice, the resident reported, he signed off on a VIP patient staying an additional night in the hospital, even when he thought the patient was ready to be discharged.

“When I allow one of my patients to be labeled ‘important,’ ” he wrote, “do I implicitly label the others as less important?”